<!DOCTYPE html>

<html>

	<head>
		<title>
			Input Personal Info Form
		</title>	
	</head>
	
	<body>
		<form>
		
			<table border="1">
		
				<tr>
					<th>
						<label for="lastName">Last Name :</label>
					</th>
					
					<td colspan="3">
						<input type="text" name="LastName" value="Vassilev" id="lastName"/>
					</td>
				</tr>

				<tr>
					<th>
						<label for="firstName">First Name :</label>
					</th>
					
					<td colspan="3">
						<input type="text" name="FirstName" value="Vassil" id="firstName"/>
					</td>
				</tr>

				<tr>
					<th>
						<label for="adress">Adress :</label>
					</th>
					
					<td colspan="3">
						<textarea name="Adress" id="adress">Baker street</textarea>
					</td>
				</tr>

				<tr>
					<th>
						<label for="city">City :</label>
					</th>
					
					<td>
						<input type="text" name="City" value="Kaspichan" id="city"/>
					</td>
					
					<th>
						<label for="state">State :</label>
					</th>
					
					<td>
						<input type="text" name="State" value="Alabama" id="state"/>
					</td>
				</tr>

				<tr>
					<th>
						<label for="postalCode">Zip/Postal Code :</label>
						
					</th>
					
					<td colspan="3">
						<input type="text" name="ZipOrPostal" value="12345" id="postalCode"/>					
					</td>
				</tr>
				
				<tr>
					<th>
						<label for="country">Country :</label>
					</th>
					
					<td colspan="3">
						<select name="Countries" id="country">
							<option value="Bul">Bulgaria</option>
							<option value="Gr">Greece</option>
							<option value="UK">United Kingdom</option>
						</select>					
					</td>
				</tr>
				
				<tr>
					<th>
						<label for="phone">
							Phone (country code,<br>
							area code, number) :
						</label>
					</th>
					
					<td>
						(+
						<input type="text" name="CountryCode" value="+359" id="phone"/>
						)
					</td>
					
					<td>
						<input type="text" name="CityCode" value="88"/>
						-
					</td>
					
					<td>
						<input type="text" name="PhoneNumber" value="85698754"/>
					</td>										
				</tr>

				<tr>
					<th>
						<label for="email">Email :</label>
					</th>
					
					<td colspan="3">
						<input type="text" name="Email" value="nakov@abv.bg" id="email"/>					
					</td>
				</tr>				

				<tr>
					<th>
						Birth Date :
					</th>
					
					<td>
						<label for="month">Month :</label>
						<input type="text" name="Month" value="06" id="month"/>					
					</td>
					
					<td>
						<label for="day">Day :</label>
						<input type="text" name="Day" value="14" id="day"/>					
					</td>
					
					<td>
						<label for="year">Year(4 digits) :</label>
						<input type="text" name="Year" value="1980" id="year"/>					
					</td>
				</tr>
								
				<tr>
					<th>
						<label for="gender">Gender :</label>	
					</th>
					
					<td colspan="3">
						<select name="Gender" id="gender">
							<option value="Male">Male</option>
							<option value="Female">Female</option>
						</select>					
					</td>
				</tr>

				<tr>
					<th>
						Starting date :
					</th>
					
					<td colspan="3">
						<input type="radio" name="Date"/>	
						Summer 2006
						<input type="radio" name="Date"/>				
						Spring 2006
					</td>
				</tr>
				
				<tr>
					<th>
						<label for="comments">Comments/Questions :</label>
					</th>
					<td colspan="3">
						<textarea name="Adress" id="comments">Please send me more information about the lodging</textarea>
					</td>
				</tr>
				
				<tr>
					<th colspan="4">
							<input type="submit" value="Apply Now" />
							<input type="reset" name="resetBtn" value="Reset the form" />
					</th>
				</tr>
				
			</table>
		
		</form>
		
	</body>
	
</html>	